<div class="container">
	<form id="patienthistoryform">
		
		<table>
			<tr>
				<td>
					<label class="searchformlabel" style="width:40%"><strong>Age(yrs.):</strong></label> 
					<input type="text" id="age" value="<%= history.get('age')%>" style="width:25%"/>
					
				</td>
				<td>
					<label class="searchformlabel"><strong>Gender:</strong></label>
					<select class="docselect" id="gender" >
						<option value="M"  <% history.get('gender')=='M'?print("selected"):""%> >Male</option>
						<option value="F" <% history.get('gender')=='F'?print("selected"):""%>>Female</option>
					</select>
				</td>
			</tr>
			<tr>
				<td>
					<label class="searchformlabel" style="width:40%"><strong>Weight(kgs.):</strong></label> 
					<input type="text" id="weight" value="<%= history.get('weight')%>" style="width:25%"/>
					
				</td>
				<td>
					<label class="searchformlabel" style="width:40%"><strong>Height(cms.):</strong></label> 
					<input type="text" id="height" value="<%= history.get('height')%>" style="width:25%"/>
				</td>
			</tr>
			<tr>
				<td>
					<label class="searchformlabel"><strong>Marital Status:</strong></label> 
					<select class="docselect" id="maritalStatus" >
						<option value="S"  <% history.get('maritalStatus')=='S'?print("selected"):""%> >Single</option>
						<option value="M" <% history.get('maritalStatus')=='M'?print("selected"):""%>>Married</option>
					</select>
				</td>
			</tr>
			<tr>
				<td>
					<label class="searchformlabel"><strong>Smoking:</strong></label> 
					<input type="checkbox" id="smoking"  <% history.get('smoking')=='Y'?print("checked"):""%>/>
					
				</td>
				<td>
					<label class="searchformlabel"><strong>Drinking:</strong></label> 
					<input type="checkbox" id="drinking" <% history.get('drinking')=="Y"?print("checked"):""%>/>
				</td>
			</tr>
			<tr>
				<td>
					<label class="searchformlabel"><strong>High blood pressure:</strong></label> 
					<input type="checkbox" id="bp" <% history.get('bp')=='Y'?print("checked"):""%>/>
					
				</td>
				<td>
					<label class="searchformlabel"><strong>Heart disease:</strong></label> 
					<input type="checkbox" id="heart" <% history.get('heart')=='Y'?print("checked"):""%>/>
				</td>
			</tr>
			<tr>
				<td>
					<label class="searchformlabel"><strong>High Cholesterol:</strong></label> 
					<input type="checkbox" id="cholestrol" <% history.get('cholestrol')=='Y'?print("checked"):""%>/>
					
				</td>
				<td>
					<label class="searchformlabel"><strong>Diabetes:</strong></label> 
					<input type="checkbox" id="diabetes" <% history.get('diabetes')=='Y'?print("checked"):""%>/>
				</td>
			</tr>
			<tr>
				<td>
					<label class="searchformlabel"><strong>Kidney disease:</strong></label> 
					<input type="checkbox" id="kidney" <% history.get('kidney')=='Y'?print("checked"):""%>/>
					
				</td>
				<td>
					<label class="searchformlabel"><strong>Asthma or Lung disease:</strong></label> 
					<input type="checkbox" id="asthma" <% history.get('asthma')=='Y'?print("checked"):""%>/>
				</td>
			</tr>
			<tr>
				<td>
					<label class="searchformlabel"><strong>Tuberculosis:</strong></label> 
					<input type="checkbox" id="tb" <% history.get('tb')=='Y'?print("checked"):""%>/>
					
				</td>
				<td>
					<label class="searchformlabel"><strong>Liver disease or hepatitis:</strong></label> 
					<input type="checkbox" id="liver" <% history.get('liver')=='Y'?print("checked"):""%>/>
				</td>
			</tr>
			<tr>
				<td>
					<label class="searchformlabel"><strong>Arthritis:</strong></label> 
					<input type="checkbox" id="arthritis" <% history.get('arthritis')=='Y'?print("checked"):""%>/>
					
				</td>
				<td>
					<label class="searchformlabel"><strong>Bleeding disorder:</strong></label> 
					<input type="checkbox" id="bleeding" <% history.get('bleeding')=='Y'?print("checked"):""%>/>
				</td>
			</tr>
			<tr>
				<td>
					<label class="searchformlabel"><strong>HIV:</strong></label> 
					<input type="checkbox" id="hiv" <% history.get('hiv')=='Y'?print("checked"):""%>/>
					
				</td>
				<td>
					<label class="searchformlabel"><strong>Cancer:</strong></label> 
					<input type="checkbox" id="cancer" <% history.get('cancer')=='Y'?true:""%>/>
				</td>
			</tr>
			<tr>
				<td>
					<label class="searchformlabel"><strong>Food Allergy:</strong></label> 
					<input type="checkbox" id="foodAllergy" <% history.get('foodAllergy')=='Y'?print("checked"):""%>/>
					
				</td>
				<td>
					<label class="searchformlabel"><strong>Food allergy details:</strong></label>
					<textarea rows="4" cols="50" id="foodAllergyDetail"> <%= history.get('foodAllergyDetail')%></textarea> 
				</td>
			</tr>
			<tr>
				<td>
					<label class="searchformlabel"><strong>Drug Allergy:</strong></label> 
					<input type="checkbox" id="drugAllergy" <% history.get('drugAllergy')=='Y'?print("checked"):""%>/>
				</td>
				<td>
					<label class="searchformlabel"><strong>Drug allergy details:</strong></label> 
					<textarea rows="4" cols="50" id="drugAllergyDetail"> <%= history.get('drugAllergyDetail')%></textarea>
				</td>
			</tr>
			<tr>
				<td>
					<label class="searchformlabel"><strong>Chemical Allergy:</strong></label> 
					<input type="checkbox" id="chemicalAllergy" <% history.get('chemicalAllergy')=='Y'?print("checked"):""%>/>
					
				</td>
				<td>
					<label class="searchformlabel"><strong>Chemical allergy details:</strong></label> 
					<textarea rows="4" cols="50" id="chemicalAllergyDetail"> <%= history.get('chemicalAllergyDetail')%></textarea>
				</td>
			</tr>
			<tr>
				<td>
					<label class="searchformlabel"><strong>Pencillin Allergy:</strong></label> 
					<input type="checkbox" id="pencillinAllergy" <% history.get('pencillinAllergy')=='Y'?print("checked"):""%>/>
					
				</td>
				<td>
					<label class="searchformlabel"><strong>Pencillin allergy details:</strong></label> 
					<textarea rows="4" cols="50" id="pencillinAllergyDetail"> <%= history.get('pencillinAllergyDetail')%></textarea>
				</td>
			</tr>
			<tr>
				<td>
					<label class="searchformlabel"><strong>Taking any medication?:</strong></label> 
					<input type="checkbox" id="medication" <% history.get('medication')=='Y'?print("checked"):""%>/>
					
				</td>
				<td>
					<label class="searchformlabel"><strong>Medication Detail:</strong></label> 
					<textarea rows="4" cols="50" id="medicationDetail"> <%= history.get('medicationDetail')%></textarea>
					
				</td>
			</tr>
		</table>
		<input type="button" id="submitphistory" value="Submit">
	</form>
	
	   
</div>